Download Zurich Australia - Group Risk - Major Illness

Group Major Illness
Medical Information Questionnaire – Treating Medical Specialist
Malignant Cancer
To be completed by the claimant’s treating medical specialist.
This questionnaire is designed to obtain information in relation to a claimant who has been diagnosed with
malignant cancer.
If there is a cost associated with the completion of the form, it is the responsibility of the claimant.
Claimant’s details
1
a. Surname (Family Name)
b. Given name/s
c. Date of Birth
/
/
History
2
a. How long have you known the claimant?
months
b. Are you the claimant’s usual treating specialist?
Yes
No
c. Has the claimant been diagnosed with this condition, or any contributing symptoms previously?
Yes
No
3
years
If ‘Yes’, when?
/
/
Details of the claimant’s Major Illness
The following questions are designed to assist Zurich in the assessment of the claimant’s insurance claim for Major Illness
Benefits. It is important that you provide detailed answers to assist us in our assessment.
a. Is there the presence of a malignant tumour, including leukaemia, lymphoma and other haemopoietic
malignancies
Yes
No
b. What is your diagnosis of the tumour? Histological examination reports in support of the diagnosis must be provided.
c. Has the cancer been classified as carcinoma in situ?
Yes
No
ZU20977 - V2 03/13 - SROE-008692-2014
d. If the claimant has been diagnosed as suffering from melanoma, please state the Clark level depth of invasion.
e. If the claimant has been diagnosed as suffering from prostate cancer, what is the TNM Classification or other relevant classification score?
f. Please describe the treatment regime the claimant has undergone, or will need to undergo in future, including details of surgeries and interventionist therapies.
Malignant Cancer Form – Page 1 of 2
4
Declaration
I hereby declare that the above statements are true and correct.
Signature of Doctor / Specialist / Consultant
Date
✗ /
/
Name
Address
Qualifications
Telephone number
Email
Privacy
Zurich is bound by the Privacy Act 1988 (Cth). In completing the forms or questions herein you will be providing us with
personal and, perhaps, sensitive information. The collection and management of this information is governed by the
Privacy Act 1988. For a more detailed explanation of Zurich’s Privacy Policy please visit our website at www.zurich.com.au
or contact the Zurich Privacy Officer on 132 687 or email us at [email protected]
Please send your completed form to:
Zurich Australia Limited
Group Risk Insurance
Locked Bag 994
North Sydney NSW 2059
Save File
Print Form
Malignant Cancer Form – Page 2 of 2